Employment Verification Form - Teacher Loan Repayment Program - State Of New Mexico, Higher Education Department
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1State of New Mexico
Higher Education Department
Teacher Loan Repayment Program (TLRP)
EMPLOYMENT VERIFICATION FORM
THIS DOCUMENT MUST BE RECEIVED VIA EMAIL BEFORE 6/15/2016
PARTICIPANT:
Printed First Name:_____________________________ Printed Last Name:_________________________________ MI:______
Participant Address___________________________________City____________________State_________Zip Code___________
Last four digits of SS#:_____________________ Current Email Address:_________________________________________
Title:________________________________________ Daytime Phone Number:__________________________________
Loan Provider:_________________________________ Account Number:_______________________________________
Loan Provider Address___________________________________City____________________State_________Zip Code___________
I hereby certify that I have completed this service quarter as required by my contract seek payment.
_______________________________________________
_________________________________
Participant Signature
Date
*Loan provider cannot be changed without prior written 60 day notification to the department.
EMPLOYER:
Employer/Institution/Facility: _________________________________________________________________________________
Name of Person Completing Form:__________________________ Title of Person Completing Form:________________________
Employer Email Address:________________________________________ Employer Phone Number:________________________
Name of Employee:________________________________________
I ___________________________ certify that the named participant above has completed continuous employment in good standing for
the period: 1/1/2016_ thru 5/31/2016 for an average of
hours per week and an average of 13 weeks per calendar
quarter, including paid leave, or any combination of hours and weeks, as further specified in the Loan Repayment Participation
Agreement executed with the Higher Education Department.
Approved Employer Signature
Date
NOTARY:
Subscribed and sworn to before me in the county of
,
State of
this
day of
,20
.
Signed:
Seal:
Title:
My Commission Expires:
This executed form must be completed in full, scanned and emailed to
fin.aid@state.nm.us
on or before June 15, 2016. Employment Verification
Forms received after June 15, 2016 will not be accepted. Forms dated or submitted prior to May 31, 2016 will not be accepted. Faxed and
mailed copies will no longer be accepted. For questions please contact the New Mexico Higher Education Department at 1-800-279-9777 or
fin.aid@state.nm.us.
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